R/F/4 days

00.69.63.06
Chief Complain : vomiting
It had been suffered by the patient since born about 4 days before
admitted to Adam Malik Hospital. Vomitted every drink breastmilk.
Excessive saliva from birth (+),history of meconium defecation from
birth (+) before 24 hours after birth.
Initially the patient was born normally with midwife. Spontaneous crying.
Patient was preterm 30 weeks, with birth weight 2.500 gr, birth length
49 cm, history of cyanotic (-). The mother had a regular ANC with
midwife. Patient was the second child. History of fever (-). Micturition
was normal, history of consumption of unprescribed drugs and other
traditional herbs was denied. History of radiation exposured was denied.
History of congenital defect in the family was denied. Patient was
refered from district hospital
Status Present:
• Awareness : alert
• HR : 150 x / min
• RR : 32 x / min
• Temp : 37.0 ° C
• BW : 2.500 gr
General Examination
• Head : no abnormalities
– Eyes : anemic conjunctive (-/-), icteric sclera(-/-)
– Mouth : Hypersalivasi (+)
• Neck : no abnormality was found
• Vertebra: no abnormalities found
• Chest : no abnormalities
• Abdomen: in localized state
• Genitalia: female, no abnormality
• Anal : female, no abnormalities
• Extremity: no abnormalities
Localized State
Abdomen:
I : Symmetric, distension (-).,
P: Soeple, palpable mass (-)
P: tymphani,
A: peristaltic (+) N
• Laboratory Finding
• Hb/Ht/L/ Plt :18.1/52/9.9/412.000
• Na / K / Cl : 135/4.3/100
• Random Glusoce Level : 161
Working diagnose :
Susp. Esophageal atresia with tracheo-
esophageal fistel
Management at the ER:

- O2 nasal 1 L/i
- Nil per mouth
- Applied of OGT
- Instalation of urine catheter with initial 4 cc 
UOP clear yellow urine 2cc/hour
- IVFD D5%:NS 0,225% 15 microdrips/i
- Inj. Antibiotic